Recovering General Surgery Is Impossible

A complete revision of payment in favor of basic services is required for any hope of more general surgeons, general orthopedists, and other general surgical workforce. Any hope of getting surgical residents to bypass prestigious fellowships in favor of direct practice entry is entirely about the financial design. A fellowship results in a career with services that are reimbursed at much higher levels. Narrowing the differential between basic and highly specialized is required for restoration of all generalist and general specialty careers.


General surgeons are shrinking along with other general surgical specialties. Production is too low to replace attrition. This has actually been going on for some time - General surgery has taken at least a 15% decline since 2005 and more likely close to 20%. The oldest general surgeons are in locations with lowest concentrations of physicians - making shortages worse. These are also the places increasing the most in population, in elderly, in demand, and in complexity - it is a nightmare set to steadily worsen for years to come.

The reason is payment design. The payment design is insufficient to support generalists and general surgery and other general surgical careers. Generalists are also strained as they are forced to pick up tasks from general surgery, orthopedics, ob-gyn, and mental health in the absence of such workforce.

The knee-jerk response is to increase training funds and general surgical trainees, but this would be a waste of funding.

No training intervention can work until there is a fix for the substantial payment disparities between lowest paid cognitive/office/basic services versus highest paid procedural/technical/highly specialized/newest. Special programs can have success, but they just end up displacing others. There is not enough payment to support any increase in the workforce. More production just drives out other sources - as seen in zero changes in primary care and ever lower proportions of MD DO NP and PA in primary care.

There is just not enough payment overall going to general surgical services and this is particularly acute for counties lowest in physician concentrations - counties that only have 21% of physicians despite 40% of the population.

Counties lowest in physician concentration have numerous disparities in physicians including psychiatrists less than 20% (to serve 40%), active physicians 21%, mental health providers 23.5%, and active practicing nurse practitioners and physician assistants 26% (worse for all NP and PA).  The deficits of generalists and general specialties matter most in lowest concentration counties as they are 70% of total workforce.

This decline in generalists and general specialties is about payment - not salaries. Higher payment does allow higher salaries, but payment means much more. Payment means profits to employers and also results in more support to be able to do more services and the highest paid services. This results in more team members to share the load and less complexity for physicians. Higher paid services also allow better team members to be hired and retained as compared to lesser paid services relegated to higher turnover, new staff, and staff unable to move on.

No increase in payment is likely from CMS or from Congress. Congress wants further cuts and CMS wants cuts and more innovation. CMS is falling behind in other functions.

Reform energy has largely been wasted and what remains regarding reform is unlikely to address increases in cognitive/office/basic services at the sacrifice of some payments from procedural/technical/highly specialized/newest.

Needed payment reforms supportive of basic services are prevented as the dominant players do not want cuts in highest paid services. Without increased payments or shifts of funding from higher paid services, there will not be a resolution of workforce gaps. Workforce cannot go where it is not supported.

New payment designs fail to discern quality in services as there is no separation from outcome influences that occur before or after health care encounters or admissions. The patient behaviors, situations, environments, determinants, and genetics as well as deficits of local resources and workforce are much greater influences compared to the provider.

The CMS designs for payment pay less for needed care of patients where disparities are present because the disparities are about people factors with providers penalized unfairly for caring for such populations.

The facilities to support general surgeons where needed are being closed. Small hospitals and practices are failing by CMS and ACA design.

Workforce failures are seen across generalists and general specialties and in the locations where generalist and general specialties are most dominant.

Lowest Paying Plans Promote Disparities.

Patients with Medicaid and Medicare and other lowest paying plans are concentrated around lowest cost of living areas, consequently lowest payments and least local supports (Veterans, Tribal, fragmentation) result in insufficient workforce. Loss of one or two key physicians or practices in a small health location can result in serious deficits.

Powerful Forces at Work Preventing Payment Reform That Matters

The forces that shape health care payment will never allow such a revision. Those who perform the highly specialized services do not want to take a pay cut, especially during a time with numerous other payment cuts impacting hospitals. Getting bigger is really important at the current time and declines in payment impair this priority. The academic and largest hospitals are dominant players in the design of reimbursement. A non-objective participant is almost always a bad idea. This gives those doing well an enhanced ability to oppose reforms in payment - successful for decades. There are a privileged few that benefit by current design including few Americans generally doing well as well as health care entities in a relatively few places with top concentrations of physicians.

Decades of receiving payment from the most lines of revenue (including GME, corporations, and others that they created), and decades of receiving the highest reimbursement in each line has resulted in great power that can be exerted to preserve the current design.

Regarding reforms of payment, the recommendations of Medicare advisory panels have been ignored. Graduate medical education reports have been ignored.

Physicians Held Hostage By SGR More Willing to Settle for Anything Else

At one point there was some reform in reimbursement for basic services in the 1990s, but the benefits were soon eaten up by increased cost of delivery. The reforms of the 1990s were temporary and were quickly reversed with a rebound. The SGR payment was a way to steadily lower costs, but once again powerful forces intervened and made SGR a huge sword of Damocles with huge cuts held off year after year.

In many ways, payment reform was never really considered as SGR played out so badly that anything looked better than what might happen. What negotiating power there was to attempt to narrow the gap between basic and highly specialized services was long gone.

Reform Energy Wasted 

The reform energy of the 1990 and 2010s time periods was far greater than exists now. It also appears that recognition and reform building takes at least 20 years to develop. The 2030s may be the earliest that a change would have the ability to address the challenge. Unfortunately the accelerating demand for generalists and general surgical services plus increasing retirements and insufficient entry will have forced entirely different solutions.

The 2010s leadership had its chance and focused upon insurance expansion and innovative payment - except they failed to focus on the one payment change that matters for 70% of the workforce needed by half of the American population.

Failures in More than General Surgery

The failures are in primary care, mental health, underserved areas, 75% of the rural population, 32% of the urban population. This is seen in 2621 counties lowest in physician concentrations with 40% of Americans. In these counties with least payment support, only 21% of physicians are found. These are counties that have been crying out for what the national design will not produce. Generalists are 46% of the workforce and general surgical specialties are about 25% - general forms of surgery, orthopedics, ob-gyn, urology, ear nose throat, ophthalmology.

Countdown of Physician Workforce in 2621 Counties Lowest in Physician Concentrations
  • FM is 25% of lowest concentration physician workforce. FM once had a role in general surgical services. FM could take up the slack from general surgery, but again the designers have prevented this with certification, liability, and training barriers. Family medicine has long been stagnant at 3000 annual graduates since the class of 1980 - an indication of unfavorable place in the overall design. FM did have top retention in primary care and in specialty, but FM is fading from 95% family practice to 75% as payments, supports, salaries are better elsewhere as seen in Emergency Medicine 12%, urgent 4%, and hospitalist 4% positions. FM docs listed in hospital based settings are 26% rural as compared to all FM at just 20% and falling. FM in the 1970s was 30% rural in location. Failed payment fails most where physicians are most needed. Salaried FM docs are the most squeezed of all by failed payment design. Small and solo practices make up 50% of family physicians and are most threatened. The declines will continue until the last 20 years are put behind with new payment and new leadership.
  • General IM was 13% of lowest concentration workforce but is collapsing to 6% or less. The payment design gives IM residency graduates substantially better choices across salary and support. In the past 15 years the hospitalist workforce has increased to 50,000 total with over 40,000 from IM training. More graduates in each class year pursue hospitalist careers than general IM. Substantial changes in payment disparities are a requirement for any return to general IM.
  • Hospitalist, emergency medicine, and urgent care are the only registered increases for lowest concentration counties - but this may be at the expense of local primary care indicating worse to come. 
  • General surgery is falling fast - over a 15% decrease in the period 2005 to 2013. Payment design takes out production. Small hospital closure takes out needed facilities. Payment design takes out small and solo practices with higher costs and decreased productivity to go with low payments for basic services common to general surgeons.
  • General orthopedics is also falling at a similar rate. In a recent study of specialists by age groups, almost every specialty had higher pay for the older physicians. Sometimes the gap was narrower as in primary care. In orthopedics the youngest and oldest physicians both had highest payment. Taking a fellowship or two appears to be most rewarded by payment design.
Behind By Design in Lowest Concentration Counties with 40% of the US Pop
  • Worst contribution is in physicians with just 21% found where 40% are found. This is made worse because of increased demand from more elderly and near elderly. These are also counties growing fastest. Only 6% of training is found in these counties but even more training would not help as there just is not the payment to support the workforce. The magnitude of the disparity is indicated by 6% of residents (and even less GME dollars) for places with 40% of the US. Reimbursement design constantly shorts care where needed.
  • Mental health providers are just 23.5% where 40% are found. The case can be made that these are places also with behavior issues across alcohol, depression, smoking, drug abuse, and children's mental health. Schools are hamstrung by lack of mental health. Less than 20% of psychiatrists and child psychiatrists are found in these counties - another indication that expansions of training will not resolve shortages. Distance to care makes matters worse. Counties with 100,000 to 200,000 are also without a psychiatrist in some states. Once again lowest payment prevents the support of enough team members in enough places to deliver the care.
  • Nurse practitioner and physician assistant workforce is promoted as a fix for care where needed, but payment less for NP and PA services has been an impediment as with other payments too low. Also NP and PA are among the most flexible, able to transition to more specialties with more added to each specialty. With widespread acceptance the NP and PA graduates are moving away from family practice and primary care to new lower proportions year after year. In the next decade the family practice proportion will be 3rd or 4th behind emergency medicine, orthopedics, and surgery. The last doubling of PA graduates resulted in 100% more entering the workforce, over 200% entering non-primary care, and less than 30% more entering primary care with this falling steadily in the years after entry.

More Dollars for Academic Centers - Even Odds 50:50

This is just the first of the media push. There will be studies and proposals with dollars sent to academic centers - but these dollars will not result in more general surgeons, nor will they replace the aging general surgeons that have shaped 2 - 3 percentage points of decline a year from 2005 to 2013. 

General Surgery Must Rise from the Ashes of the Last 20 Years - but must join the generalist and general specialty crowd in deficit.
No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.

The blogs represent the opinion of the blogger alone.
Copyright 2016


  1. SGR was a sucking chest wound. MACRA slapped on a piece of duct tape, and declared, "All better now!!"


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